Prevention of soccer injuries

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Prevention of soccer injuries Supervision by doctor and physiotherapist JAN EKSTRAND,* MD, JAN GILLQUIST, MD, AND STEN-OTTO LILJEDAHL, MD From the Department of Surgery, University Hospital,

1 Prevention of soccer injuries Supervision by doctor and physiotherapist JAN EKSTRAND,* MD, JAN GILLQUIST, MD, AND STEN-OTTO LILJEDAHL, MD From the Department of Surgery, University Hospital, Linköping, Sweden ABSTRACT To study the efficacy of an injury prevention program in a randomized trial, 12 teams (180 players) in a male senior soccer division were followed up for 6 months. The 12 teams were allocated at random to two groups of six teams, one being given a prophylactic program and the other serving as control. The program was based on previous studies of injury mechanisms. It comprised (1) correction of training, (2) provision of optimum equipment; (3) prophylactic ankle taping; (4) controlled rehabilitation; (5) exclusion of players with grave knee instability; (6) information about the importance of disciplined play and the increased risk of injury at training camps; and (7) correction and supervision by doctor(s) and physiotherapist(s). The injuries in the test teams were 75% fewer than in the controls. The most common types of soccer injuries, sprains and strains to ankles and knees, were all significantly reduced. It is concluded that the proposed prophylactic program, including close supervision and correction by doctors and physiotherapists, significantly reduces soccer injuries. * Address correspondence to Jan Ekstrand, MD, Department of Orthopaedic Surgery, University Hospital, S Linkoping, Sweden 116 Ten percent of all injuries treated at hospitals are sports injuries. ~ 1,1~ The need for prevention has been emphasized&dquo;,&dquo; but prevention has not kept pace with the early diagnosis and treatment of sports injuries. No randomized studies on the efficacy of a prophylactic program have apparently been done. As soccer is the most popular sport in the world, with more than 22 million participants, 1 &dquo;>,18 we chose to study this sport. A study of etiological factors is the first step in injury prevention. In studies on incidence of injury, exposure, and injury mechanisms in soccer, we have found that threefourths of all injuries are probably preventable.3-6 On the basis of these findings, we have devised a prophylactic program. The purpose of the present study was to test the program in a randomized trial. MATERIALS AND METHODS A senior male soccer division of 12 teams was studied during the first 6 months of Each team coach selected the 15 best players for the study before the season s start in January. The 12 teams were randomized into two groups of six teams. In a preseason test, all 180 players were examined for past injuries and persistent symptoms from past injuries, and the musculoskeletal profile in the lower extremities was analysed by stability tests and measurements of range of movement (ROM) and strength. The teams in Group A (aged 24.3 ± 3.7, range 17 to 37 years) were given a program with prophylactic measures, and those in Group B (aged 24.7 ± 4.1, range 17 to 36 years) served as controls. The prophylactic program consisted of seven parts. 1. Correction of training No shooting at the goal was allowed before warmup. A special warm-up routine lasting 20 minutes was worked out, and this replaced all calisthenics and dynamic stretching exercises. The program started with 10 minutes of general an exercise in warmup with the ball, using &dquo;the square,&dquo; which four to six players form a square and pass the ball back and forth with one to two players in the middle who try to touch the ball. The ball exercise was followed by a 10- minute flexibility program consisting of contract-relax stretching exercises for the adductors, quadriceps, hamstrings, iliopsoas, and triceps surae.~ ~~ 19 Each practice session was followed by a 5-minute cooldown program consisting of jogging and hold-relax stretching exercises for the lower extremities.

117 All coaches were instructed in taping, and taped the players before matches. Players were instructed to tape themselves before all practice sessions.

Before training, anchor strips followed by stirrups and horseshoe strips were applied.

2 117 All coaches were instructed in taping, and taped the players before matches. Players were instructed to tape themselves before all practice sessions. The skin was protected with a foam wrap (J-Wrap, Johnson & Johnson, New Brunswick, New York), over which a 1.5-inch Coach tape (Johnson & Johnson) was applied. Before training, anchor strips followed by stirrups and horseshoe strips were applied. Before matches this was complemented with a figure of eight lock around the heel to support the lateral structures.8 4. Controlled rehabilitation A special rehabilitation scheme for lower extremity injuries was worked out. This gradually increased the stress on the injured leg, and step by step adapted the player for return to play. Return to games and practice was determined by doctor and physiotherapist, and a full, painfree ROM and regain of 90% of muscle strength was mandatory. 5. Exclusion of players with knee instability Figure 1. Sportoped shin guard. One player with anterolateral rotational instability (ALRI) was advised to give up soccer, and was replaced by another player. 6. Information Information was given to coaches and players about (1) the importance of disciplined play and the risk of serious ownfoul injuries (injuries occuring to players violating the rules according to referee judgement), and (2) the increased incidence of injury at training camps and how to avoid such injury. z 7. Correction and supervision 2. Equipment Figure 2. Adidas soccer special training shoe. All players were provided with Sportoped (Casco/USA, Fort Lauderdale, FL) leg guards (Fig. 1), the use of which was compulsory in all games and practice sessions. During winter training, players were provided with Adidas Soccer Special training shoes (Adidas, Herzogenaurach, West Germany, Fig. 2). 3. Prophylactic ankle taping All players with previous ankle sprains and/or clinical instability had their ankles taped prophylactically. Forty-three of 90 players (52 ankles) were taped. Doctors and physiotherapists regularly attended practice sessions and games to supervise the prophylactic measures. Corrections were made if the measures were not followed or were wrongly administered. Attendance records during games and practice sessions were kept by each coach, who reported weekly all injuries. An injury was defined as any injury occurring during games and practice sessions and causing the player to miss the next game or practice session. Injuries were classified into three categories, according to severity (see Table 1). All injuries in both groups were examined and treated by the same orthopaedic surgeon. The results were treated statistically by the usual methods. (See Table 2 for results.) RESULTS Figure 3 shows injuries per month. The six control teams had a mean of 2.6 injuries per month during the first 6 months of 1981, an incidence equal to the mean for all 12 teams in the division during the same period of By using the prophylactic program, the six test teams reduced their injuries to an incidence of 0.6 per month, which is 75%

3 - (combinations 118 TABLE 1 Definitions applicable to the study An attempt was made to study the efficacy of the different features of the prophylactic program (Table 3) since they were directed against different types of injury. In every instance the test group had fewer injuries than the controls. Some injuries in the test group are explained by disregard of the program; 23 strains occurred in the control group, whereas the test group showed only 6 (P < 0.001). The control group had 11 ankle sprains, and the test group 2 (P < 0.05). Both ankle sprains in the test group affected players who should have taped their ankles prophylactically. One player sustained the injury at the first practice session in January, before the coach had given instructions, and the other neglected the recommendations. In the test group none TABLE 2 Comparison between test teams and control teams concerning injuries, operations, and absence from practice sessions and games Figure 3. Injuries per team per month during the first 6 months of 1980 and during the same penod of TABLE 3 Connection between injuries and the prophylactic program of factors were seen in the control group) less than in the control group (P < 0.001). Table 3 shows the number of injuries, operations performed, and absence from practice and games. The test group had 23 injuries, and the controls 93 (P < 0.001). The test-team players were absent from 111 practice sessions and 48 games because of injury; the corresponding figures for the controls were 476 and 215 (P < 0.001). Eleven operations were performed in control players but only two on test-team players (P < 0.05). The most common injuries, strains and sprains to ankles and knees, were fewer in the test group (P < 0.05 to 0.001). No significant difference in distribution between minor and major injuries was found between the two groups. Sixteen of 23 (70%) of the injuries in the test group were traumatic, compared to 72 of 93 (77%) in the controls (not significant). In the test group, 15 of 23 (65%) of the injuries were sustained during games; in the controls the corresponding figures were 54 of 93 (58%) (not significant).

119 of the 52 ankles that were prophylactically taped sustained a strain, whereas 9 of 11 ankle injuries in the control group occurred among players with a past history of ankle sprain and/or

4 119 of the 52 ankles that were prophylactically taped sustained a strain, whereas 9 of 11 ankle injuries in the control group occurred among players with a past history of ankle sprain and/or clinical instability (P < 0.05). No reinjuries were seen in the test group, but 31 of 93 of the injuries in the control group were reinjuries (X2 = 8.83, P < 0.001). Inadequate rehabilitation was the main factor in 13 of the 31 cases (Table 3). Two control players with ALRI sustained three knee sprains, and one of these underwent reconstructive surgery during the period. Eight foul-play injuries occurred among controls, but only one in the test group. Nine of 12 teams took part in the same division during With regard to team success, expressed as number of points, during the first 6 months of 1981 and the same period of 1980, no significant difference was found between the five teams in the test group and the four in the control group. DISCUSSION We have been unable to find any report on tests of efficacy of a prophylactic program for ball sports in a randomized trial. The 75% reduction of injuries in our test group was achieved with a program comprising seven prophylactic measures. The program was devised after careful study of incidence, type, and localization of soccer injuries and the mechanisms behind them.3 6 In previous studies on the same soccer division we analysed the history of previous injuries and persistent symptoms following past injuries, type and localization of injuries,~ incidence of injuries and the relation between injury and training,5 the relation between injuries as well as strength, and flexibility.6 On examination before the season, soccer players were less flexible than a reference group of nonplayers of the same age. Sixty-seven percent of the players had one or several tight muscles in the lower extremity. ~ In a prospective study we found a correlation between muscle tightness and strains.6 However, we found no correlation between muscle tightness and previous injuries. The cause of muscle tightness in soccer players seems to be associated with training methods. 5 In a field study5 we found the mean duration of the warmup to be adequate, but its content was not apparently ideal from the clinical point of view. Although 90% of injuries involved the lower extremities, exercises for the upper part of the body were as usual as leg exercises. Strains mainly affected leg muscles such as the adductors, hamstrings, and quadriceps; nevertheless, only half of the teams performed special exercises for these muscles. Furthermore, all flexibility exercises were of the dynamic type, although it has been shown that contract-relax stretching is more effective than dynamic stretching. Another explanation for muscle tightness could be the nonuse of cool-down.5 Moller et al.12 found a reduction in ROM in the lower extremities lasting two to three days after a series of hard quadriceps and hamstrings exercises. When strength exercises were immediately followed by contractrelax stretching of the same muscles, the reduction in ROM was eliminated. Similar results were noted after soccer training (M. Moller, personal communication). As soccer players practice or play three to four times each week, accumulation of the muscle stiffness resulting from a single exercise could partly explain their muscle tightness. We constructed a special prophylactic warm-up program with contract-relax stretching for the legs combined with a cool-down program after the training session. In another study we found that this program increased ROM by 5 to 20%.19 We also noticed that shooting at the goal before warmup was common, and was related to quadriceps strains.5 Shooting at the goal before warmup was therefore not allowed in the prophylactic program. Compared to use in sports such as ice-hockey, protective equipment is less important in soccer. From the clinical point of view, shin guards commonly used in soccer have been considered too small and not sufficiently shock absorbent.16 Moreover, they are rarely used. The shin guard used by our test group is anatomically shaped and protects a large area. We urge the compulsory use of shin guards of this type to reduce injuries. We support the suggestion by Roaas and Nilsson 17 that players with traumatic lower-leg injuries should receive financial compensation only if approved shin guards were used. As ankle sprain is the most common soccer injury, as well as in many other sports, the need for prevention is great. Prophylactic ankle taping is frequently used, but apart from this study and that of Garrick and Requa on basketball players, little evidence has been presented confirming its value. The selection of players for taping has also been discussed.&dquo; Taping of all ankles is probably too costly and time consuming for most teams. With our specifications, all injuries but two were prevented, and both of these players should have been taped. We therefore believe that our method is effective and realistic. Soccer players with ALRI are rare (3/180 in this study). They have considerable difficulties and also show a high incidence of reinjury, and we suggest that they either give up soccer altogether or undergo a reconstructive operation. The many reinjuries reflect lack of knowledge among players and coaches concerning rehabilitation after injury. When postinjury return to practice and matches was determined to be safe by player and coach (as in the control group), a high incidence of reinjury was noted. Controlled rehabilitation (as in the test group) under supervision of a physiotherapist or doctor, and special rules for players and coaches concerning rehabilitation and return to play, reduce the rate of reinjury. This is especially important for knee injuries as players show reduced muscle strength for several years even though they have resumed their sport and believe themselves fully rehabilitated.2,lo Care of minor injuries is probably also important because minor injuries often precede major ones.4 It may be argued that a prophylactic program steals time from the actual soccer training and that worry about injuries can make players less aggressive. In other words, a prophy-

5 120 lactic program could diminish the success of a team. However, we found no such adverse effect. Supervision and correction of training was an important part of the program. For most teams, however, it is not realistic to expect help from doctors and physiotherapists, and it is therefore important to test the efficacy of the program in the hands of the coaches, without supervision. It is also difficult to assess how much the different features of the program contribute to the total effect. Certain points, such as change of training methods, could have a more general effect, cutting down the number of several different injuries. An analysis has to be made, therefore, of which features are the most useful components. ACKNOWLEDGMENTS The study was supported by grants from the Research Council of the Swedish Sports Association, Ostergotlands Lans Landsting. The Faculty of Medicine, University of Linkoping, and the insurance companies Folksam and Trygg-Hansa. The statistical advice of E. K. Leander, PhD, is gratefully acknowledged. REFERENCES 1 Armitage P Statistical Methods in Medical Research Oxford, Blackwell Scientific Publications, Arvidsson, I, Enksson E, Haggmark T, Johnson RJ Isokinetic thigh muscle strength after ligament reconstruction in the knee joint Int Journal Sports Med , Ekstrand J, Gillquist J The frequency of male tightness and injuries in soccer Am J Sports Med , Ekstrand J, Gillquist Soccer injuries and their mechanisms A prospective study Med Sci Sports, in press, Ekstrand J, Giliquist J, Moller M, Oberg B, Liljedahl SO Incidence of soccer injuries and their relation to training and team success Am J Sports Med , Ekstrand J, Gillquist J The avoidability of soccer injuries Int J Sports Med in press, Franke K Traumatologie des Sports. Berlin, VEB, Verlag, Volk und Gesundheit, Garrick JG, Requa RK: Role of external support in the prevention of ankle sprains Med Sci Sports , Grahn R, Nordenborg T, Wallin D, Nystrom J, Kblom B Improvement of muscle flexibility comparisons between two techniques Scand J Sports Science In press, Grimby G, Gustavsson E, Peterson L, Renstrom P Quadriceps function and training after knee ligament surgery Med Sci Sports , Liljedahl SO, Giliquist J Idrottsskador Svenska Utzildnings-Forlaget Liber AB, Malmõ, Sweden Moller M, Oberg B, Ekstrand J, Gillquist J: The effect of a strength training program on flexibility (Abstract) Swedish Society of Sportsmedicine, Are, Nicholas JA Injuries in sports Recent developments. Orthop Clin North AM , O Donoghue DH Treatment of injuries to athletes Second edition Philadelphia, W B Saunders Company, Pardon ET Lower extremities are site of most soccer injuries Physician Sportsmed , Renstrom P, Peterson L Fotbollsskador Fotbollsplan med konstgras Valhalla idrottsplats i Goteborg Rapport Naturvårdsverket SNV PM 846, Roaas, A, Nilsson S Major injuries in Norwegian football Br J Sports Med , Smodlaka VN Rehabilitation of injured soccer players Physician Sportsmed , Wiktorsson-Moller M, Oberg B, Ekstrand J, Gillquist J The effect of warming up, massage and stretching on range of motion and muscle strength of the lower extremity Am J Sports Med in press

Hip Strains. Anyone can experience a hip strain just doing everyday tasks, but strains most often occur during sports activities.

Hip Strains. Anyone can experience a hip strain just doing everyday tasks, but strains most often occur during sports activities. Hip Strains A hip strain occurs when one of the muscles supporting the hip joint is stretched beyond its limit or torn. Strains may be mild, moderate, or severe, depending on the extent of the injury.